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Aneurysms of the Vertebral and Posterior Inferior Cerebellar Arteries

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Aneurysms of the Vertebral and Posterior Inferior Cerebellar Arteries Aneurysms of the vertebral and posterior inferior cerebellar arteries Hanna Lehto, MD Department of Neurosurgery Helsinki University Central Hospital Helsinki, Finland and Faculty of Medicine University of Helsinki Helsinki, Finland Academic Dissertation To be publicly discussed with the permission of the Faculty of Medicine of the University of Helsinki, in Lecture Hall 1 of Töölö Hospital on April 17th 2015, at 12 noon. Vkirja_viite_255246_LEHTO_.indd 3 30.3.2015 15.09 Vkirja_viite_255246_LEHTO_.indd 2 30.3.2015 15.09 Supervisors: Professor Juha Hernesniemi Department of Neurosurgery Helsinki University Central Hospital Helsinki, Finland Associate Professor Mika Niemelä Department of Neurosurgery Helsinki University Central Hospital Helsinki, Finland Reviewers: Associate Professor Timo Kumpulainen Department of Neurosurgery Oulu University Hospital Oulu, Finland Associate Professor Topi Siniluoto Deparment of Radiology Oulu University Hospital Oulu, Finland Opponent: Professor Andreas Gruber Department of Neurosurgery Medical University of Vienna Vienna, Austria ISBN 978-951-51-0901-9 (paperback) ISBN 978-951-51-0902-6 (PDF) http://ethesis.helsinki.fi Unigrafia, Helsinki, 2015 Vkirja_viite_255246_LEHTO_.indd 3 30.3.2015 15.09 Table of contents ORIGINAL publications ............................................9 ABBREviations ............................................................11 ABSTRACT ......................................................................13 17 INTRODUCTION 21 REVIEW OF THE LITEraturE Cerebral artery aneurysms and subarachnoid hemorrhage ......................21 Incidence and prevalence .............................................................21 Diagnostics ...................................................................................21 Risk Factors ...................................................................................21 Morphology and etiology ..............................................................21 Histology ...................................................................................... 22 Genetics ....................................................................................... 22 Treatment ..................................................................................... 22 Outcome .......................................................................................23 Preventive treatment .....................................................................23 Posterior circulation aneurysms ............................................................. 24 Definition ..................................................................................... 24 Incidence ...................................................................................... 24 Location ....................................................................................... 24 Special features compared to anterior circulation ...................... 24 History of treatment ..................................................................... 24 The vertebral artery and the posterior inferior cerebellar artery ............... 27 Anatomy ....................................................................................... 27 Controversies in nomenclature ....................................................31 Aneurysms ....................................................................................31 Treatment ......................................................................................35 Outcome .......................................................................................37 41 AIMS OF THE STUDY 43 PatiENTS AND METHODS Patients .....................................................................................................43 Data and analysis ......................................................................................44 Radiological data ..........................................................................44 Follow-up data ..............................................................................45 Statistical analysis ........................................................................45 Vkirja_viite_255246_LEHTO_.indd 4 30.3.2015 15.09 47 REsults Incidence of vertebral and posterior inferior cerebellar artery aneurysms ......................................................................47 Anatomy of aneurysms at junction of the vertebral artery and the posterior inferior cerebellar artery .....................................47 Patients and aneurysms ...............................................................47 PICA aneurysms ...........................................................................47 Variations of VA and PICA ............................................................48 Jugular tubercle ............................................................................48 Overview of patients with vertebral artery or posterior inferior cerebellar artery aneurysms ..........................................51 Patients and aneurysms ................................................................51 Treatment ..................................................................................... 52 Outcome ......................................................................................56 Patients with ruptured vertebral or posterior inferior cerebellar artery aneurysms ..................................................................... 60 Patients and aneurysms .............................................................. 60 Treatment and angiographic outcome ........................................63 Clinical outcome ......................................................................... 64 Patients with unruptured vertebral artery or posterior inferior cerebellar artery aneurysms .........................................................72 Overview ......................................................................................72 Ruptured aneurysm in another location ......................................72 Ruptured arteriovenous malformation .......................................76 Mass effect ...................................................................................76 Ischemia .......................................................................................77 Incidental aneurysms...................................................................78 81 DISCUSSION Incidence .................................................................................................. 81 Anatomic features .................................................................................... 81 Location ....................................................................................... 81 Morphology ..................................................................................82 Anatomy of VA–PICA aneurysms in CTA .....................................82 Treatment ..................................................................................................82 Surgical treatment and radiological outcome .............................83 Endovascular treatment and radiological outcome ....................83 Choosing the treatment modality and techniques .....................84 Outcome ..................................................................................................84 Future perspectives ..................................................................................84 Etiology of VA and distal PICA aneurysms ...................................84 Future treatment ..........................................................................84 Conclusion ................................................................................................ 85 ACKNOWLWDGEMENT ................................................87 LITEraturE .................................................................. 91 ORIGINAL publications .........................................111 Vkirja_viite_255246_LEHTO_.indd 5 30.3.2015 15.09 Vkirja_viite_255246_LEHTO_.indd 6 30.3.2015 15.09 Original publications I Lehto H, Kivisaari R, Niemelä M, Dashti R, Elsharkawy A, Harati A, Satopää J, Koroknay-Pál P, Laakso A, Hernesniemi J.: Seventy Aneurysms of the Posterior Inferior Cerebellar Artery: Anatomical Features and Value of Computed Tomography Angiography in Microneuro-surgery. World Neurosurgery, 2014 82(6):1106 – 1112 II Lehto H, Harati A, Niemelä M, Dashti R, Laakso A, Elsharkawy A, Satopää J, Billon-Grand R, Canato B, Kivisaari R, Hernesniemi J.: Distal posterior inferior cerebellar artery aneurysms: Clinical features and outcome of 80 patients. World Neurosurgery, 2014 82(5):702 – 713 III Lehto H, Niemelä M, Kivisaari R, Laakso A, Jahromi BR, Hijazy F, Andrade H, Dashti R, Hernesniemi J: Intracranial vertebral artery aneurysms: Clinical features and outcome of 190 patients (World Neurosurgery, accepted) The original publications here are reproduced here with the permission of the copyright holders. 9 Aneurysms of the vertebral and posterior inferior cerebellar arteries Vkirja_viite_255246_LEHTO_.indd 7 30.3.2015 15.09 Vkirja_viite_255246_LEHTO_.indd 8 30.3.2015 15.09 Abbreviations ACA ........ Anterior cerebral artery AICA ...... Anterior inferior cerebellar artery AcomA .. Anterior communicating artery AVM ....... Arteriovenous malformation AVF ........ Ateriovenous fistula BA .......... Basilar artery CCA ....... Common carotid artery CI ........... Confidence interval CN .......... Cranial nerve CSF ........ Cerebrospinal fluid CT .......... Computed tomography CTA ........ Computed tomography
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